R e v i s t a d a S o c i e d a d e B r a s i l e i r a d e M e d ic in a T r o p ic a l 2 5 ( 3 ) : 1 5 5 - 1 6 0 , j u l - s e t , 1 9 9 2
ARTIGOS
FU L M IN A N T HEPATITIS WITH M ICROVESICULAR
STEATOSIS (A HISTOLOGIC COM PARISON OF CASES
OCCURRING IN BRAZIL -
LA B R E A H E P A T IT IS
- A N D IN
CENTRAL AFRICA -
B A N G U I H E PA T IT IS )
Z i l to n A . A n d r a d e , J e a n L . L e s b o r d e s , P a u l R a v is s e , R a i m u n d o P a r a n á ,
A lu íz io P r a t a , J o ã o S . B a r b e r i n o a n d C h r i s t i a n T r e p o
A s i m i la r h is to p a th o lo g ic p i c t u r e o f f a t a l h e p a titis a s s o c ia te d w ith w id e s p r e a d a c u te f a t t y c h a n g e s in h e p a to c y t e s a n d s in g le - c e l l n e c r o s is w a s s e e n in e p id e m ic c a s e s o c c u r r in g in tw o d is ti n c t e q u a to r ia l a r e a s h a v in g h ig h p r e v a l e n ç e s o f H B V a n d H D V in fe c tio n s . T h e c a s e s w e r e p r e v i o u s l y c o n s i d e r e d to b e tw o d if f e r e n t e n titie s ; Labrea hepatitis in B r a z il, a n d Bangui hepatitis
in th e C e n tr a l A f r ic a n R e p u b lic . H o w e v e r , th e h is to p a th o lo g ic f i n d i n g s s u g g e s t t h a t th e y a r e p a th o g e n e t ic a l ly a n d e tio lo g ic a lly r e l a te d to H B V a n d H D V in f e c tio n s , p r o b a b l y m o d if ie d b y
s o m e a s y e t u n k n o w n f a c t o r (s ) p r e s e n t in e q u a to r ia l f o r e s t zo n e s .
K e y - w o r d s : Labrea hepatitis. Bangui hepatitis. D e lta in fe c tio n . S p o n g io c y tic h e p a titis .
A p e c u lia r, h ig h ly fa ta l fo rm o f h ep a titis, a ffe c tin g p rim a rily c h ild re n a n d y o u n g a d u lts , and
o c c u rrin g in m ic ro e p id e m ic s h a d b ee n d esc rib ed in th e A m a z o n ia n re g io n o f B ra zil as L a b re a fe v e r3 4 9 10 12, in C o lo m b ia as S a n ta M a rta fe v e r7 14 26 a n d in th e F re n c h G u y a n a as A m az o n ia n B lack F e v e r 22. M o re re c e n tly it h a s also b e e n o b s e rv e d in Y u c p a In d ia n s in V e n e z u e la 15 24 an d lin k e d to in fe c tio n h e p a titis D e lta v iru s (H D V ).
T h e c lin ic o -p a th o lo g ic a l p ic tu re is th a t o f an a c u te h e p a titis w ith s p o tty c o a g u la tiv e a n d ly tic
ce ll n e c ro s is a n d a c u te fa tty c h a n g e, w ith sw o llen , m u ltiv a c u o la te d h ep a to c y tes, w h ic h h a s b e e n called
“ m o ru la r” o r “ s p o n g io c y tic ” ce lls 3 4 9 10 12.
G e o g ra p h ic a lly th e se ca ses h a v e be e n re p o rte d fro m E q u a to ria l a re a s o f S o u th A m eric a, areas w h ic h a lso h a v e h ig h p re v a le n c e s fo r h ep a titis B
a n d h e p a t i t i s D e l t a v i r u s c a r r i e r s t a t e . E p i d e m i o l o g i c a l f i n d i n g s 8, a l o n g w ith th e d e m o n s tra tio n o f H B s A g , H B cA g an d D e lta a n tig e n in th e liv e r ce lls , so m etim e s w ith th e p re s e n c e o f D e lta a n tig e n w ith in th e n u clei o f m o ru la r h e p a to c y te s 13 h a v e s tro n g ly su p p o rte d th e
Gonçalo M oniz Research Center/FiOCRUZ; Federal Univer sity o f Bahia (U F B A ), Salvador, BA and University o f Brasilia (UnB), Brasilia, Brazil; PB 6 bis, Tananarive, Madagascar; Institut Pasteur, Paris and Hepatitis INSERM Unit 69372, Lyon, France.
A d d r e s s to : Dr. Zilton de Andrade. Centro de Pesquisa
Gonçalo M oniz. R. Valdemar Falcão 121, 41295-001 Salva dor, BA , Brasil.
Recebido para publicação em 12/03/92.
a ssu m p tio n th a t H D V w a s th e e tio lo g ic a l a g e n t o f th is p e c u lia r ty p e o f h e p a titis. H o w e v e r, th e re h a s be e n so m e re lu c ta n c e in ac c e p tin g su c h a n etio lo g y sin ce th e a s so c ia tio n o f H B V a n d h e p a titis D e lta v iru s in fe c tio n in o th e r p a rts o f th e w o r ld 17 n e ith e r r e p r o d u c e t h e p e c u l i a r c l i n i c a l f e a t u r e s (m ic ro e p id e m ic s, p sy c h ic a g ita tio n a n d b la c k b lo o d y v o m i ts ) , n o r th e c h a ra c te ris tic h is to p a th o lo g ic a l h e p a tic c h a n g es s e e n in th e ca ses f r o m th e A m az o n ia n re g io n s , e x c ep t fo r a n o c c asio n al is o la te d c a s e 18.
R e c e n tly , e x am p les o f fa tal h e p a titis w ith d iffu se acu te fatty cha ng es in he p a to c y tes h a v e b e e n d esc rib ed as s p o n g io c y tic h e p a titis in th e re g io n o f B a n g u i in C en tra l A fric a 20, w h ic h is also a n e q u a to ria l fo re st area w ith h ig h p re v a le n c e o f H B V a n d h e p a titis D e lta v iru s in fe c tio n s.
C o m p a ra tiv e stu d ies b e tw e e n th e ca ses w h ic h o c c u r in th o s e tw o re g io n s se e m im p o rta n t to fu r th e r c larify th e p o ssib le co m m o n etio lo g y o f th ese p e c u lia r form s o f hepa titis. T h erefo re, th e p re s e n t in v estig atio n co n sists o f a c o m p a ra tiv e h is to lo g ic a l stu d y o f ca ses o f L a b r e a h e p a t i t i s see n in B ra z il a n d s im ila r cases o b se rv e d b y o n e o f u s (JL L ) in B a n g u i, c a p ita l o f th e C en tra l A fric a n R e p u b lic .
M A T E R IA L A N D M E T H O D S
L a b r e a h e p a t i t i s c a se s. T a b le 1 s u m m a riz e s th e m ain c lin ical fin d in g s. E ig h t o f th e n in e ca ses s h o w n h e re h a v e be e n p re v io u s ly re p o rte d 13. S ev en ca ses
A n d r a d e Z A , L e s b o r d e s J L , R a v is s e P , P a r a n á R , P r a ta A , B a r b e r in o J S , T r e p o C . F u lm in a n t h e p a titis w ith m i c r o v e s i c u la r s t e a t o s i s (A h is to lo g ic c o m p a r is o n o f c a s e s o c c u r r in g in B r a z il - Labrea hepatitis - a n d in C e n tr a l A f r ic a
- B angui hepatitis). R e v is t a d a S o c ie d a d e B r a s ile ir a d e M e d ic in a T r o p ic a l 2 5 : 1 5 5 - 1 6 0 , ju l - s e t , 1 9 9 2 .
w e re fro m L a b re a , a sm all v illa g e in th e n o rth w e s t p a r t o f th e A m a z o n a s state in B ra z il, n e a r th e B o liv ia n b o rd e r; o n e o th e r ca m e fro m P o rto V e lh o , R o n d o n ia , a n a re a in th e so u th w e st A m az o n ia n re g io n a n d a n o th e r w a s fro m S a lv a d o r, B a h ia 1, a la rg e p o r t c ity o n th e B ra z ilia n ea ste rn co ast.
B a n g u i h e p a t i t i s . S even u n p u b lish e d cases w e re se le c te d as re p re s e n ta tiv e o f th e ep id em ic .
C rite ria in c lu d e d p re sen ce o f clin ic al data com patib le w ith a c u te fu lm in a n t h e p a titis an d th e fin d in g o f s p o n g io c y tic h e p a to c y te s at h is to lo g y . T h e m ain clin ic a l fin d in g s a r e s h o w n in T a b le 2. S e ro lo gica l
T a b le 1 - G e n e r a l d a t a fi-o m n in e c a s e s o f Labrea hepatitis.
Nr S ex A g e (yrs)
Duration (days)
H D A g Hbsag Hbcag
1* F 11 1 + +
-2 * M 11 3 - +
-3* M 4 6 + +
-4* M 16 7 - -
-5* F 9 4 + + +
6* M 2 3 + + +
y* M 9 4 - +
-8* M 4 7 - -
-9 F 8 ? - -
-* C a s e s p r e v i o u s l y p u b l i s h e d .
T a b le 2 - G e n e r a l d a ta f r o m s e v e n c a s e s o f fu lm in a n t
B angui hepatitis.
N r S ex A g e Duration H D A g Hbsag H bcag (yrs) (days)
1* M 17 1 + + +
2* F 18 2 + + +
3 * * M 29 1 + + +
4** M 24 1 - -
-M 27 4 + -
-6 ** F 15 1 - -
-7 * * M 2 4 2 + +
-H istology: * I.ahrea simile. ** Severe acute hepatitis with spongiocytic cells, *** Coagulative necrosis + polymorpho nuclear leukocytes + spongiocytic cells.
d a ta w e re o b ta in e d fro m all ca ses. R e su lts w e re n e g a tiv e fo r y e llo w fe v er, h e m o rrh a g ic fe v ers (W est
N ile , R if t V a lle y , L a ss a , M a rb u rg , E b o la ). S era w e re also te ste d b y im m u n o flu o re s c e n c e a n d w e re in o c u la te d in to s u c k lin g m ice an d p lace d o n c e llu la r c u ltu re (V e ro E 6 - A P 61 ) a t th e In s titu t P a ste u r B a n g u i to c o m p le te th e stu d y fo r th e id e n tific a tio n o f a r b o v ir u s e s , a lw a y s w ith n e g a tiv e re s u lts.
A p p ro x im ately 20 0 sim ila r cases h av e been o b serv ed in th e C en tra l A fric a n R e p u b lic s in c e 1 9 8 2 19.
F ra g m e n ts o f liv e rs w e re o b ta in e d a t n e c ro p sy in m o st o f th e ca ses a n d b y n e e d le p o s t - m o r t e m “b io p s y ” . T h ey w e re fix e d in n e u tra l 10% fo rm a lin and em b ed d e d in p a ra ffin . S ectio n s w e re s ta in e d w ith h em ato x y lin & eo sin an d re p re sen ta tiv e sectio ns w e re a d d itio n a lly sta in e d w ith th e fo llo w in g : 1. G o m o ri’s re tic u lu m ; 2. M a s s o n ’s tric h ro m e ; 3.
p e rio d ic ac id S c h iff (P A S ), a n d 4. p ic ro s iriu s re d fo rco lla g en . A n im m u no pe ro xid ase (P A P ) tech niq ue fo r th e d e m o n stra tio n o f H b sa g , H b c a g an d D e lta antig en w a s p e rfo rm e d o n p a ra ffin se c tio n s fro m all th e ca ses, as d es c rib e d e lse w h e re fo r th e B raz ilian cases23.
R e p re s e n ta tiv e w e t-tiss u e b lo c k s w e re c u t o n a freez in g m ic ro to m e a n d th e se c tio n s sta in e d w ith
S u dan B lack fo r th e d e m o n stra tio n o f fat.
R E S U L T S
T h e B ra z ilian ca ses w e re strik in g ly s im ila r to
o n e a n o th e r an d w ill be d e s c rib e d first. G en eral lo b u la r a rc h ite c tu re o f th e liv e r w a s p re se rv e d . T he- p r e s e n c e o f sw o lle n an d v a c u o la te d liv e r c e lls, w ith a ce n tral n u cleu s an d a sp o n g y o r m o ru la r cy to p la s m d o m in a te d th e p ic tu re (F ig u re s 1 an d 2 ). T h e s e ce lls
Figure 1 - Labrea hepatitis o f seven d a y duration. There can be seen paren ch ym al disa rra y, sw ollen a n d vacu olated hepatocytes, fo c a l dropping out o f liver cells, abnorm al b ile d u c t a n d m o n o n u c le a r - c e ll in f iltr a tio n . H em atoxylin & E osin , 2 5 0 X.
ap p eared th ro u g h o u t th e sectio ns w ith n o p re fe re n tia l
A n d r a d e Z A , L e s b o r d e s J L , R a v i s s e P , P a r a n á R , P ra ta A , B a r b e r in o J S , T r e p o C. F u lm in a n t h e p a t itis w ith m ic r o v e s ic u la r s t e a to s i s (A h is to lo g ic c o m p a r is o n o f c a s e s o c c u r r in g in B r a z il- L a b r e a h e p a t it is - a n d in C e n tr a lA fr i c a - B a n g u i h ep a titis,). R e v is ta d a S o c i e d a d e B r a s ile ir a d e M e d ic in a T r o p ic a l 2 5 : 1 5 5 -1 6 0 , j u l- s e t, 1 9 9 2 .
V a c u o l e s s ta in e d s t r o n g l y f o r f a t ( F i g u r e 3 ) S id e b y
s i d e w i t h t h e v a c u o l a r c h a n g e s th e r e w a s ly tic
n e c r o s i s ( d r o p p i n g o u t ) o f li v e r c e lls a s w e ll a s
d i f f u s e i n f i l tr a ti o n b y m o n o n u c le a r le u k o c y te s . N o
m a s s iv e o r s u b m a s s iv e n e c r o s i s w a s e v e r s e e n , th e
s i l v e r i m p r e g n a te d h e p a t i c r e t i c u l u m a p p e a r e d
g e n e r a lly p r e s e r v e d , a l th o u g h w it h m i c r o s c o p ic
f o c i o f c o n d e n s a tio n , e s p e c ia lly a r o u n d t h e c e n tr a l
a n d s u b lo b u la r v e in s ( F i g u r e 4 ) .
C o a g u la tiv e n e c r o s i s w a s a ls o p r e s e n t, b u t n o t
a s f r e q u e n tly o r d is s e m i n a te ly a s th e v a c u o l a r o r
l y tic c h a n g e s . U s u a ll y t h e c o a g u la ti v e s in g le - c e ll
n e c r o s i s d i d n o t f o r m d e n s e , r o u n d , h y a l i n e
c o rp u s c le s , b u t e x h i b i te d a r a th e r s m u d g y a n d
i r r e g u la r a p p e a r e n c e . A s f o r t h e in f l a m m a to r y c e lls ,
m a c r o p h a g e s a n d ly m p h o c y t e s w e r e p r o m i n e n t ,
p o ly m o r p h o n u c le a r n e u t r o p h i ls a n d e o s in o p h il s
b e in g e x tr e m e ly r a r e .
P o r t a l s p a c e s s h o w e d e d e m a , c h r o n i c
in f la m m a tio n a n d d u c tu la r p r o l i f e r a t i o n . T h e s e
c h a n g e s b e c a m e m o r e e v i d e n t in th e c a s e s o f m o r e
p r o lo n g e d d u r a t io n . W it h ti m e , th e a c c u m u la ti o n o f
le u k o c y te s in th e p o r ta l s p a c e s a ls o in c r e a s e d ( F ig u r e
5 ) a n d th e p r o l if e r a te d b i l e d u c ts e x h i b it e d a t y p ic a l
h y p e r p la s ia . E v e n in is o la te d d u c ta l s tr u c tu r e s ,
a b n o r m a l b i l e d u c t e p it h e li u m e x h i b i t e d v a c u o la te
e n la r g e d a n d h y p e r c h r o m a ti c n u c le i ( F i g u r e 6 ) .
M o r p h o lo g ic a l s ig n s o f c h o le s ta s is , r e p r e s e n te d b y
b i l e t h r o m b i, b i l e im p r e g n a ti o n o f d u c ta l a n d
p a r e n c h y m a l c e lls , w e r e s e e n i n m o s t o f th e c a s e s ,
b u t n e v e r r e p r e s e n t e d a p r o m i n e n t c h a n g e .
P o s it iv e s ta i n in g f o r D e l t a a n ti g e n w a s f o u n d in
4 c a s e s . T h e a n t i g e n a p p e a r e d a s a d a r k
h o m o g e n e o u s , p e r o x i d a d e - p o s itiv e s p o t in th e n u c le i
o f h e p a to c y te s , a lw a y s s c a tte re d a n d f e w in n u m b e r s ,
th e m a x im u m o b s e r v e d in a 4 0 x m ic r o s c o p ic f ie ld
b e in g 4 .
T h e e x a m in e d B a n g u i c a s e s c o u l d b e d iv id e d
in to th r e e g r o u p s : th e f ir s t w a s r e p r e s e n t e d b y tw o
c a s e s w h i c h e x h i b i t e d e x a c t l y t h e s a m e
h is to p a th o lo g ic a l p i c t u r e a s t h e c a s e s d e s c r ib e d
a b o v e . T h e s e c o n d g r o u p c o n s is te d o f o n e c a s e , th a t
b e s id e s h a v i n g th e f e a tu r e s o f th e p r e v io u s c a s e s ,
p r e s e n t e d h y a l i n e c o a g u l a t i v e n e c r o s i s a s a
c o n s p ic u o u s c h a n g e . I n a d d i ti o n , s u c h l a t t e r c h a n g e
w a s a c c o m p a n ie d b y f o c a l a n d m a r k e d in f i lt r a t i o n
o f p o ly m o r p h o n u c le a r le u k o c y t e s ( F i g u r e 7 ) . T h e
s p o n g y h e p a t o c y te s a p p e a r e d m i n g le d w i t h th e
h y a li n e n e c r o ti c c e lls a n d th e p o l y m o r p h o n u c l e a r
le u k o c y te s . S u c h a c o m b i n a ti o n o f c h a n g e s h a d n o t
b e e n o b s e r v e d in t h e B r a z il ia n c a s e s . T h e th ir d
g r o u p w a s r e p r e s e n t e d b y 4 c a s e s w h ic h p r e s e n te d
th e c la s s ic a l f e a tu r e s o f s e v e r e a c u te v i r a l h e p a t it is
A n d r a d e Z A , L e s b o r d e s J L , R a v is s e P , P a r a n á R , P r a ta A , B a r b e r in o J S , T r e p o C. F u lm in a n t h e p a t itis w ith m ic r o v e s ic u la r s t e a to s i s (A h is to lo g ic c o m p a r i s o n o fc a s e s o c c u r r in g i n B r a z i l - L a b r e a h e p a t it is - a n d i n C e n tr a lA fr ic a - B a n g u i h e p a titis,). R e v is ta d a S o c i e d a d e B r a s ile ir a d e M e d ic in a T r o p ic a l 2 5 : 1 5 5 -1 6 0 , j u l - s e t , 1 9 9 2 .
F i g u r e 5 - L a b r e a . h e p a t i t i s . A b n o r m a l, h y p e r p l a s t i c a n d d e g e n e r a t e d b ile d u c t s in a p o r t a l s p a c e w i th d e n s e m o n o n u c l e a r - c e l l in fil tr a tio n . T h e in fl a m m a t o r y c e lls s e e m to p e n e t r a t e d a n d d i s s o c i a t e t h e li m it in g p a r e n c h y m a l la m in a (" s p ill -o v e r '') . M a s s o n tr i c h r o m e s t a i n , 1 2 0 X .
F i g u r e 6 - B a n g u i h e p a t i t i s . A c u t e h e p a tit is w ith p r o m i n e n t v a c u o l a r o r ' 's p o n g i o c y t i c " c h a n g e s in h e p a t o c y t e s , p l u s h y a l i n e s i n g l e - c e l l n e c r o s i s a n d in fl a m m a t io n w it h m o n o n u c l e a r a n d p o l y m o r p h o n u c l e a r le u k o c y tic in fi l tr a ti o n . H e m a to x y l in & E o s i n , 1 2 0 X .
F i g u r e 7 - B a n g u i h e p a t i t i s . D e t a i l s h o w i n g t h e h e p a to c y ti c f a t t y c h a n g e s a n d m o n o n u c l e a r - c e l l in fil tr a tio n .
H e m a to x y l in & E o s i n , 2 0 0 X .
w it h s u b m a s s iv e n e c r o s i s a n d c o l la p s e , b u t h a v i n g
in a d d itio n m a n y p a r t ia ll y o r to ta lly m u l ti v a c u o la te d
h e p a to c y te s , e it h e r s c a tte r e d o r in s m a ll c lu s te r s
( F i g u r e 8 ). S ig n s o f c h o l e s t a s is in th e s e la s t f o u r
c a s e s w e r e m u c h m o r e e v i d e n t th a n in th e B r a z ilia n
c a s e s .
D I S C U S S I O N
T h e p r e s e n t c o m p a r a t iv e s tu d y r e v e a ls th a t th e
s e v e re a n d p e c u li a r f o r m o f a c u te h e p a t it is o c c u r r i n g
in S o u th A m e r ic a a n d in C e n tr a l A f r i c a , w h i c h
s h a r e s a s im il a r e q u a to r ia l e c o lo g ic a l b a c k g r o u n d ,
a ls o p r e s e n ts s im il a r h i s t o p a th o l o g ic a l f e a tu r e s .
T h e B r a z ilia n c a s e s s tu d ie d w e r e a p p a r e n tl y m o r e
h o m o g e n e o u s th a n th e A f r i c a n o n e s . T h is m a y b e
r e la te d to c a s e s e le c tio n , w h ic h is lin k e d to th e
m a tte r o f c o n c e p tu a l d e f i n i ti o n .
Labrea hepatitis
inB r a z il h a s b e e n p r i m a r i ly c o n s id e r e d a s a c lin ic a l
e n tity w h ic h o c c u r s i n m ic r o e p id e m ic s , a f f e c ts
c h i ld r e n , p r e s e n ts a f u l m in a n t c o u r s e a n d s h o w s
p r o m i n e n t
signs
o f c e n t r a l n e r v o u s s y s t e mi n v o l v e m e n t3 . C a s e s c o n s id e r e d a s c la s s ic a l a c u te
f u l m in a n t v ir a l h e p a titis o c c u r r i n g in th e s a m e
g e o g r a p h ic a r e a in a d u l ts a r e s e p a r a te d f r o m L a b r e a
h e p a titis a n d a r e n o t u s u a lly s u b m itte d to h is to lo g ic a l
e x a m in a tio n . W h e n u n s e l e c te d c a s e s o f f u lm in a t
h e p a t i t i s f r o m t h e A m a z o n i a n r e g i o n w e r e
c o n s id e r e d , a v a r i a b le h is to lo g ic a l p i c t u r e w a s
d e m o n s tr a te d . D ia s a n d C o u r a 11 r e p o r t e d o n 2 8
s u c h u n s e le c te d c a s e s , f r o m w h ic h 11 p r e s e n te d th e
classical
h is to lo g ic a l f e a tu r e s o f L a b r e a h e p a ti ti s , 5 s h o w e d s o m e b u t n o t a ll c h a r a c t e r is ti c s o f th a tc o n d i ti o n a n d 5 p r e s e n t e d c la s s ic a l a c u te h e p a ti ti s
w i t h m a s s i v e o r s u b m a s s i v e n e c r o s i s . T h i s
c o r r e s p o n d s to a p p r o x i m a t e l y th e s a m e s itu a tio n
o b s e r v e d in C e n tr a l A f r ic a .
T h e r e f o r e , in b o t h r e g i o n s a m o d if ie d f o r m o f
a c u t e s e v e r e h e p a t i t i s w i t h t h e p r e s e n c e o f
m u l ti v a c u o la te d h e p a to c y te s ( s p o n g y o r m o r u la r
t r a n s f o r m a t i o n ) s e r v i n g a s h a l l m a r k s c a n b e
o b s e r v e d .
D if f u s e h e p a to c y tic a c u te f a tty c h a n g e s w ith
c e ll s w e llin g a r e a w e l l k n o w n to x ic m a n if e s t a t io n
w h ic h m a y b e a s s o c ia te d w it h a c u t e f a tty li v e r o f
p r e g n a n c y 6, te tr a c y c l in e t h e r a p y 16 a n d h y c a n th o n e
in to x ic a tio n 2. I t h a s b e e n c o n s id e r e d a s a c o n s e q u e n c e
o f im p a ir m e n t o f lo w d e n s ity lip o -p r o te in m e ta b o lis m
A n dr a d e Z A , L e s b o r d e s J L , R a v is s e P , P a r a n á R , P r a ta A , B a r b e r in o J S , T r e p o C . F u lm in a n t h e p a titis w ith m i c r o v e s i c u la r s t e a t o s i s (A h is to lo g ic c o m p a r is o n o f c a s e s o c c u r r in g in B r a z i l - Labrea hepatitis - a n d in C e n tr a l A f r ic a - B angui hepatitis,). R e v is t a d a S o c ie d a d e B r a s ile ir a d e M e d ic in a T r o p ic a l 2 5 : 1 5 5 - 1 6 0 , j u l - s e t , 1 9 9 2 .
T h e a s s o c ia tio n w ith s u p e rin fe c tio n o f h e p a titis B v iru s c a rrie rs b y th e h ep a titis D e lta v iru s is stro n g ly su g g e ste d b y ep id e m io lo g ic a l, sero lo g ica l a n d im m u n o h is to lo g ic a l fin d in g s in b o th series, w h ic h w e re c o n s id e re d h e re . A d d itio n a l u n k n o w n e tio lo g ic fa c to rs, e n v iro n m e n ta l fa cto r(s) p re se n t in e q u a to ria l fo re s t a re a s m ay also p la y ro le s . F u rth e r stu d ie s a re n e c e ss a ry to c la rify th is v e ry im p o rta n t p o i n t . C o - i n f e c t i o n w i t h o t h e r i m p o r t a n t h e p a to tro p ic v iru s e s , su c h as h e p a titis C an d E v iru s e s , h a s n o t b e e n in v e stig a te d in th e p re sen t se rie s. A lth o u g h t H E V h a s n o t so fa r b e e n re p o rte d fro m th e areas stu d ie d h e re , th e s o -c alle d n o n -A , n o n -B h e p a titis is n o t ra re in B razil o r A frica5.
F in a lly , p re lim in a ry re s u lts o f tra n sm issio n o f th e B a n g u i s tr a in o f H D V to W H V c a r r ie r w o o d c h u c k s su g g e s t th a t th e a b n o rm a l p ro p o rtio n o f s e v e re h e p a titis fo rm s re sp o n sib le fo r th ese e q u a to ria l o u tb re a k s m ay in fact b e d u e to a m o re c y to p a th ic s tra in o f H D V 21 25.
R E S U M O
U m q u a d r o h is to p a t o ló g i c o s im ila r d e h e p a tite f a t a l , a s s o c ia d o a m u d a n ç a s a d ip o s a s a g u d a s , m u ito e s p a lh a d a s e m h e p a tó c i to s e n e c r o s e u n ic e lu la r , f o i v is to em c a s o s e p i d ê m i c o s o c o r r e n d o e m d u a s d i f e r e n t e s á r e a s e q u a to r ia is , c o m a lta p r e v a l ê n c i a d e in f e c ç õ e s H B V e H D V . O s c a s o s f o r a m p r e v i a m e n t e c o n s id e r a d o s c o m o s e n d o d u a s e n tid a d e s d if e r e n te s : hepatite de Labrea n o B r a s i l e hepatite d e B angui n a R e p ú b lic a d a A f r ic a C e n tr a l. C o n tu d o , o s a c h a d o s h is to p a to ló g ic o s s u g e r e m q u e s ã o p a t o g ê n i c a e e tio lo g ic a m e n te r e la c io n a d o s a in f e c ç õ e s H B V e H D V , p r o v a v e l m e n t e m o d if ic a d o s p o r a lg u m f a t o r a in d a d e s c o n h e c id o , p r e s e n t e n a s z o n a s de. f l o r e s t a e q u a to r ia l.
P a la v r a s - c h a v e s : Hepatite d e Labrea. Hepatite de B angui. I n f e c ç ã o d e lia . H epatite espongioçítica.
R EF E R E N C E S
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